New cholesterol guidelines put patient in driver's seat

8. Cholesterol levels drop There is evidence that ex-smokers have higher HDL ("good" cholesterol) concentrations than current smokers. The positive change happens in less than three weeks, with no clear pattern of change after that. ALSO READ: Teams With the Most Hall of Famers(Photo: HYWARDS / Getty Images)

In early November, revised expert recommendations were announced that promise to improve how millions of patients around the world with potentially dangerous elevated cholesterol values are treated with combinations of lifestyle changes and drug therapies. New strategies for risk assessment were also included.

It had been five years since the American College of Cardiology and American Heart Association compiled their last set of recommendations for health care providers about optimal strategies to manage one of the most potent predictors of cardiovascular disease — high cholesterol levels.

The 2013 guidelines stirred controversy among physicians like myself who manage complex blood fat disorders, because of a de-emphasis of target low-density lipoprotein cholesterol (LDL-C, the “bad cholesterol”) in favor of percentage drops from baselines. Also, many felt the guidelines' 10-year coronary heart disease risk calculator overestimated risk in some populations and underestimated it in others, thereby limiting its value in sorting out which patients should be treated. More solid, evidence-based data have become available that unequivocally validated treatment strategies based on LDL-C levels.

Assuming your LDL-C level has been measured and is felt to be elevated, the primary approach remains lifestyle modification to reduce cardiovascular risk. The American Heart Association's “Life’s Simple Seven” is a good starting point for anyone at increased risk. These include knowing and controlling one’s blood pressure, cholesterol and blood sugar; being active; improving dietary habits; losing excess weight and stopping tobacco use. I would add getting enough sleep to this list.

It these lifestyle changes are inadequate, further steps may be necessary or recommended. And be aware that cholesterol levels are dominantly genetically determined, so a thin, athletic person who eats a perfect diet can have dangerously elevated cholesterol levels, and overweight couch potatoes who buy meat by the pallet can have normal levels.

Statins remain the medication of choice to lower LDL-cholesterol levels. Validated in clinical trials involving hundreds of thousands of patients, statins have been unequivocally proven to reduce risk of a cardiovascular ailment. Despite all the conspiracy advocates and fringe health channels of information, the actual risk of adverse effects is small and usually dose-dependent. But there are patients who cannot tolerate statins or still have elevated cholesterol despite maximum doses.

Here’s where the new guidelines have their greatest impact. Clinical trials have demonstrated that non-statin agents can reduce cardiovascular risk as well as statins, so the guidelines give health care providers recommendations about drugs like generic ezetimibe, which blocks cholesterol absorption from the gut, and the previously expensive PCSK9 antibodies like alirocumab or evolocumab.

Rigorously compiled data on patients treated with all manner of effective therapies have demonstrated that for every 40 mg/dL of LDL-cholesterol lowering, there is a bit more than a 20 percent lowering of cardiovascular risk. It does not matter how you lower your cholesterol level to receive this benefit.

The new guidelines have also appropriately put patients back in the driver’s seat. They encourage your health care provider to discuss your preferences about treatment options, including declining them. This is especially germane if your calculated risk is in the equivocal range on whether to start taking a statin. The new guidelines, for the first time, also include the option of getting a coronary calcium scan. If there is any evidence of disease by calcium score, even without symptoms, or if one is in a very high risk category like diabetics, smokers or those with chronic kidney disease, then initiation of medication is recommended.

And if your cholesterol levels are still not where you and doctors think they should be, then the addition of PCSK9 inhibitors should be considered. The biopharmaceutical industry recently recognized that high pricing of these potent agents has been a barrier, so changes are underway, especially for Medicare patients.

The new guidelines recognize that lower LDL-C levels are better, that patients should have a voice in the decision making, that coronary calcium scores can help with the decision to start statins, and that non-statin therapies have a clear role.

Irving Kent Loh, M.D., is a preventive cardiologist and the director of the Ventura Heart Institute in Thousand Oaks. Email him at drloh@venturaheart.com.